Purpose: Cities are expanding rapidly in middle-income countries, but their supply of acute care services is unknown. We measured acute care services supply in seven cities of diverse economic background. Methods: In a cross-sectional study, we compared cities from two high-income (Boston, USA and Paris, France), three upper-middle-income (Bogota, Colombia; Recife, Brazil; and Liaocheng, China), and two lower-middle-income (Chennai, India and Kumasi, Ghana) countries. We collected standardized data on hospital beds, intensive care unit beds, and ambulances. Where possible, information was collected from local authorities. We expressed results per population (from United Nations) and per acute illness deaths (from Global Burden of Disease project). Results: Supply of hospital beds where intravenous fluids could be delivered varied fourfold from 72.4/100,000 population in Kumasi to 241.5/100,000 in Boston. Intensive care unit (ICU) bed supply varied more than 45-fold from 0.4/100,000 population in Kumasi to 18.8/100,000 in Boston. Ambulance supply varied more than 70-fold. The variation widened when supply was estimated relative to disease burden (e.g., ICU beds varied more than 65-fold from 0.06/100 deaths due to acute illnesses in Kumasi to 4.11/100 in Bogota; ambulance services varied more than 100-fold). Hospital bed per disease burden was associated with gross domestic product (GDP) (R 2 = 0.88, p = 0.01), but ICU supply was not (R 2 = 0.33, p = 0.18). No city provided all requested data, and only two had ICU data. Conclusions: Urban acute care services vary substantially across economic regions, only partially due to differences in GDP. Cities were poor sources of information, which may hinder their future planning. © 2013 The Author(s).
We conducted a descriptive cross-sectional study of supply of several measures of acute care services in a convenience sample of seven cities with a population of at least 100,000 from different geographic and economic strata: on the basis of World Bank criteria, two cities from high-income countries (Boston, USA and Paris, France), three from upper middle-income countries (Bogota, Colombia; Recife, Brazil; and Liaocheng, China), and two from lower-middle-income countries (Chennai, India and Kumasi, Ghana). We defined supply of acute care services as the number of each service per 100,000 population and per population-adjusted measure of disease burden. With local collaborators, we determined supply from data provided by local and regional authorities and conducted primary data collection when required. We determined the denominators of population and disease burden from existing census data and the Global Burden of Disease (GBD) project [7]. We chose two denominators because neither is ideal. Population data are more likely to be measured similarly across countries and with reasonable accuracy but fail to reflect the varying demand placed on acute care services by variation in disease incidence. Disease burden is thus better theoretically but is measured less accurately. We obtained approval for the study from the University of Pittsburgh Institutional Review Board (# PRO11110256) and local institutional officials as required for any prospective collection of facilities data. The population count for each city included its urban agglomeration, defined as the population in the city and adjacent suburbs [8]. We obtained the latest urban population estimates (2010–2012) from the United Nations, demographic yearbooks [9, 10], and respective national census and local administrative data [11–16]. The GBD project assesses cause-specific mortality to estimate health loss from diseases, injuries, and risk factors for all regions of the world [17]. Extending that method, we chose the number of deaths due to acute illnesses as our standard metric for disease burden. Our goal was not to measure the total burden, but rather to have a measure, proportional to burden, that permits the calculation of population-adjusted rates of supply of acute care services. The advantage of focusing on mortality is that we could rely on the GBD project, the world’s largest and most comprehensive effort to measure disease burden. The two limitations are that assignment of cause-specific mortality is prone to error and differences in case-fatality rates across cities confound the assumption that deaths are proportional to disease burden (see “Limitations”). We abstracted data from the 2008 GBD project update [7], which estimates the number of deaths per country in multiple categories of diseases. The 2008 data are the latest available at the required level of granularity. Two investigators (NKJA, SM) independently selected all communicable and non-communicable diseases whose burden would potentially be mitigated by acute care services. Disagreements were resolved by consensus of all study investigators. We selected the following illnesses: respiratory infections (otitis media, lower, and upper respiratory infections), injuries (road traffic accidents, poisoning, falls, fires, drowning, self-inflicted injuries, violence due to war and civil conflicts), and other acute illnesses (tuberculosis, diarrheal diseases, childhood-cluster diseases, meningitis, malaria, tropical-cluster diseases, dengue, Japanese encephalitis, nephritis and nephrosis, cardiovascular and respiratory diseases, maternal conditions, and diabetes mellitus). The sum of deaths across all categories was defined as the number of deaths due to acute illnesses. For each city, we estimated the number of deaths due to acute illnesses as number of deaths due to acute illnesses in the country × (city population/country population). We performed similar calculations using GBD age categories of 0–14, 15–59, and 60 years and over. We developed a data collection instrument (see “Appendix”) to gather information on the numbers of hospitals, hospital beds, ICU beds, and ambulances available in each city to serve the general population. Our goal was to create standard definitions applicable for all selected cities. After pilot testing and revision, our final instrument used the following definitions. Hospitals (including pediatric hospitals): those with an emergency department and capable of managing acute community-acquired illnesses, including government and private hospitals that provided substantial public access, as adjudicated by local collaborators. Hospital beds: staffed, acute care, non-neonatal beds capable of delivering intravenous fluids, medications, and oxygen. ICU beds: staffed with higher intensity nursing than available on acute care wards and the ability to provide oxygen therapy, pulse oximetry, vasopressors or invasive hemodynamic monitoring (e.g., ability to measure central venous pressure), and invasive mechanical ventilation. Self-defined ICU beds: as defined by the region or hospital, regardless of whether the definition agreed with our standardized definition. Ambulances: vehicles (including those operated by the fire department) that transport acutely ill patients from home to hospitals and vice versa, excluding vehicles that solely transport patients between hospitals. To obtain data, we identified local collaborators in each city. We circulated data collection instruments via email and held monthly conference calls to provide clarification and updates on the data collection process. Each collaborator collected data between January and September 2012. Collaborators first attempted to obtain data from government sources. If data were unavailable, collaborators conducted web searches and contacted other local data sources or individual hospitals, as required. We kept a log of all efforts to collect data. For each city, we calculated acute care services supply (hospitals, hospital beds, ICU beds, and ambulances) per 100,000 population and per 100 deaths due to acute illnesses. We also calculated disease burden as the total deaths due to all acute illnesses, respiratory infection deaths, and deaths due to injury per 100,000 population. For each disease burden category, we also calculated subtotals by age. We tested using regression statistics for any linear or non-linear relationship between supply of acute care services per 100 deaths and national gross domestic product (GDP) per capita, obtained from the World Bank [18]. Unless otherwise stated, when comparing ICU beds, we used the standardized rather than ‘self-defined’ count. We enumerated the barriers to data collection identified by our local collaborators. All data management and analyses were conducted using SPSS version 19 (IBM, Armonk NY) and Microsoft Excel 2007 (Microsoft, Redmond WA).
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